CMS Releases 2016 Value-Based Payment Modifier Results

The Centers for Medicare and Medicaid Services (CMS) recently released the 2016 Value-Based Payment Modifier (VBPM) results. Medicare Administrative Contractors (MACs) will begin paying claims to reflect the VBPM results with updated payment amounts after March 14, 2016. CMS anticipates practices will start seeing the adjustments on their claims within the next six weeks. CMS will need to reprocess 2016 claims with dates of service that were paid prior to this date. Also, those with pending informal review decisions may see later changes as a result of CMS’ final determination. CMS reports that over 1,000 groups still have a PQRS or VBPM informal review pending.

In 2016, all practices with 10 or more eligible professionals (EPs) are subject to the VBPM based on their 2014 performance data. The VBPM is a program that started in 2015, when the modifier applied to practices of 100 or more EPs only. This modifier will adjust Medicare Part B payments based on performance compared to national averages on quality and cost data. Learn more about how CMS calculates quality and cost performance for this programs by clicking on the VBPM tab of this blog. This performance information is also highlighted in the 2014 Quality and Resource Use Reports (QRUR), which can be accessed through the CMS QualityNet website.

Below are some highlights from the overall 2016 VBPM results shared by CMS:

128 groups out of 13, 813 total groups impacted by the VBPM exceeded the program’s benchmarks for quality and cost and will receive an increase of 15.92 percent (70 groups) or 31.84 percent (58 groups) depending on their performance score.

59 groups did not meet performance thresholds and will see a -1 percent or -2 percent decrease in 2016 payments made under the Medicare Physician Fee Schedule depending on their performance score.

Approximately 5,500 groups will receive a 2 percent penalty in 2016 for not reporting the required PQRS data in order for CMS to calculate VBPM scores. Note that this penalty will be applied in addition to the separate PQRS penalty a physician would also be assessed for not meeting the minimum reporting criteria in the PQRS program.

A majority of groups (8,208) will see no changes to their payments. This was often a result of having insufficient valid data for CMS to make quality and/or cost calculations.

In 2017, the VBPM will apply to practices of all sizes as well as individual physicians. Take a look at our resources on the Quality Time with the NCMS blog to better understand how this program will impact you in the coming years. As a result of the Medicare Access and Chip Reauthorization Act (MACRA), the VBPM program will sunset in December 2018 when CMS will transition to the new Merit-Based Incentive Payment System. Learn more about what this critical legislation does to reform the Medicare payment program by clicking on the MACRA tab of this blog.